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Smoking Patterns and Receipt of Cessation Services Among Pregnant Women in Argentina and Uruguay

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Smoking Patterns and Receipt of Cessation Services Among Pregnant Women in Argentina and Uruguay HHS Public Access Author manuscript Author ManuscriptAuthor Manuscript Author Nicotine Manuscript Author Tob Res. Author Manuscript Author manuscript; available in PMC 2017 May 01. Published in final edited form as: Nicotine Tob Res. 2016 May ; 18(5): 1116–1125. doi:10.1093/ntr/ntv145. Smoking Patterns and Receipt of Cessation Services Among Pregnant Women in Argentina and Uruguay Mabel Berrueta, MD1, Paola Morello, MD, MPH1, Alicia Alemán, MD2, Van T. Tong, MPH3, Carolyn Johnson, PhD4, Patricia M. Dietz, DrPH3, Sherry L. Farr, PhD3, Agustina Mazzoni, MD1, Mercedes Colomar, MSc2, Alvaro Ciganda BInfoTech2, Laura Llambi, MD2, Ana Becú, BMid1, Luz Gibbons, MSc1, Ruben A. Smith, PhD3, Pierre Buekens, MD, PhD4, Jose M. Belizán, MD, PhD1, and Fernando Althabe, MD, MSc1 1Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina 2Clinical and Epidemiological Research Unit, Montevideo, Uruguay 3Division of Reproductive Health/NCCDPHP, Centers for Disease Control and Prevention, Atlanta, GA 4Tulane School of Public Health and Tropical Medicine, New Orleans, LA Abstract Introduction—The 5A’s (Ask, Advise, Assess, Assist, and Arrange) strategy, a best-practice approach for cessation counseling, has been widely implemented in high-income countries for pregnant women; however, no studies have evaluated implementation in middle-income countries. The study objectives were to assess smoking patterns and receipt of 5A’s among pregnant women in Buenos Aires, Argentina and Montevideo, Uruguay. Methods—Data were collected through administered questionnaires to women at delivery hospitalizations during October 2011–May 2012. Eligible women attended one of 12 maternity hospitals or 21 associated prenatal care clinics. The questionnaire included demographic data, tobacco use/cessation behaviors, and receipt of the 5A’s. Self-reported cessation was verified with saliva cotinine. Results—Overall, of 3400 pregnant women, 32.8% smoked at the beginning of pregnancy; 11.9% quit upon learning they were pregnant or later during pregnancy, and 20.9% smoked throughout pregnancy. Smoking prevalence varied by country with 16.1% and 26.7% who smoked throughout pregnancy in Argentina and Uruguay, respectively. Among pregnant smokers in Argentina, 23.8% reported that a provider asked them about smoking at more than one prenatal care visit; 18.5% were advised to quit; 5.3% were assessed for readiness to quit, 4.7% were Corresponding Author: Mabel Berrueta, MD, Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS), Dr Emilio Ravignani 2024 (C1414CPT), Ciudad de Buenos Aires, Argentina. Telephone/Fax: 54-11-4777-8767 extension 48; [email protected]. Declaration of Interests None declared. Berrueta et al. Page 2 provided assistance, and 0.7% reported follow-up was arranged. In Uruguay, those percentages Author ManuscriptAuthor Manuscript Author Manuscript Author Manuscript Author were 36.3%, 27.9%, 5.4%, 5.6%, and 0.2%, respectively. Conclusions—Approximately, one in six pregnant women smoked throughout pregnancy in Buenos Aires and one in four in Montevideo. However, a low percentage of smokers received any cessation assistance in both countries. Healthcare providers are not fully implementing the recommended 5A’s intervention to help pregnant women quit smoking. Introduction Smoking during pregnancy is associated with many adverse outcomes for both the mother and baby including placental complications, intrauterine growth retardation, low birth weight, preterm birth, stillbirth, neonatal death, reduced infant lung function, infant neurodevelopment problems, and sudden infant death syndrome.1–4 Smoking is high among women of reproductive age in Argentina (13%–23%) and Uruguay (16%–22%),5,6 and prevalence of smoking during pregnancy is estimated to be 11% and 18%, for Argentina and Uruguay, respectively.7 However, it is unknown what percentage of women who smoked before pregnancy quit when they learn they are pregnant or later during pregnancy and reasons why women quit in these two countries. Some women stop smoking spontaneously when they find out they are pregnant.7 To support these women and those who cannot quit on their own, clinician counseling is recommended by the World Health Organization,8 and has been shown to modestly increase quits and reduce the risk of preterm delivery and low birth weight.9 As pregnancy is a time of frequent contact with health professionals, healthcare providers may help to improve maternal and infant health by systematically identifying and providing counseling to pregnant patients who currently or recently used tobacco. The 5A’s (Ask, Advise, Assess, Assist, and Arrange) is a best-practice and evidence-based approach for delivering cessation counseling to all smokers.9,10 This strategy has been implemented in several countries, including low and middle income countries.11 Since 2011 in Argentina,12 and since 2009 in Uruguay,13 national tobacco control programs have recommended brief cessation counseling interventions based on, or equivalent to, the 5A’s; however, training and resources for this approach have not been delivered to healthcare providers at a national level. Thus, it is unknown the extent to which the 5A’s for smoking cessation are being implemented by prenatal care providers. The study objectives are to assess smoking patterns and describe receipt of the 5A’s for smoking cessation during pregnancy among women attending prenatal care in publicly-funded clinics in Buenos Aires, Argentina and Montevideo, Uruguay. The data from the current study uses baseline data from a cluster randomized- controlled trial of brief counseling to help pregnant women quit smoking. Approximately, 99% of the childbirths in these countries are attended at maternity hospitals; 70% and 50% of childbirths take place in publicly-funded hospitals in Argentina and Uruguay, respectively, which are funded by the ministries of health and free of charge. Prenatal care is provided by physicians and midwives, and over 94% of pregnant women receive prenatal care during at least four visits during pregnancy (a mean of seven visits). Women attending these publicly-funded centers come from the most deprived economic sectors in both Nicotine Tob Res. Author manuscript; available in PMC 2017 May 01. Berrueta et al. Page 3 countries.14,15 These data can be used to inform national tobacco control efforts and prenatal Author ManuscriptAuthor Manuscript Author Manuscript Author Manuscript Author care practices in both countries. Methods Data Collection Our study used baseline data from a cluster randomized-controlled trial prior to implementing a brief smoking cessation counseling intervention. Trial results are not yet available, but detailed methodology is published elsewhere.16 Prenatal clinics were selected for the main trial if they served more than 250 unique pregnant women per year, did not have a smoking cessation program based on the 5A’s for pregnant women, and had physicians, midwives or nurses as part of their clinic staff. Women were eligible for the current study if they attended one of 21 prenatal clinic clusters and delivered in one of 10 public hospitals in the Province of Buenos Aires, Argentina or one of two hospitals in Montevideo, Uruguay, during October 2011–May 2012. Women with mental or physical impairments that prevented them from being interviewed and women with a diagnosis of stillbirth at admission to the hospital were ineligible to participate. All consecutively eligible women who signed an informed consent were included until a sample of 100–200 women per cluster was achieved, as required for the main trial.13 Interviews were conducted face-to-face within the first 48 hours after delivery and was administered by trained interviewers. Data were collected on paper forms and entered in each country in a secure web data open source management system (OpenClinica).17 The questionnaire was adapted from a previous study on tobacco use during pregnancy conducted in Argentina, Uruguay and other countries in 2005,7 additional questions were added, and questionnaire was pilot-tested again from November 2010 to February 2011. The questionnaire included questions on basic demographics, prenatal care characteristics, tobacco use and cessation behaviors, second-hand smoke exposure, and receipt of cessation counseling during the prenatal care visits. Data collectors within 12 hours after delivery asked eligible women two questions about their smoking status and women who reported smoking cessation as soon as they found out they were pregnant or later during pregnancy were asked to provide a saliva sample Biochemical verification was not conducted among women who reported not smoking prior to pregnancy or if they continued to smoke during pregnancy, as the risk of misclassification in these groups are likely low18 Women were asked to gently chew on the cotton swab insert from a Salivette (Sarstedt, Newton, NC). The Salivettes were stored in a refrigerator at the hospital for up to 1 month, transferred to a central freezer in each country, and shipped to the US Centers for Disease Control and Prevention laboratory in Atlanta, Georgia, for analysis. Salivary cotinine was measured by high-performance liquid chromatography atmospheric- pressure chemical ionization tandem mass spectrometry.19,20 After analysis was completed, the saliva samples were disposed of accordingly. The study was approved by the ethics committees
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